Documente Academic
Documente Profesional
Documente Cultură
ABSTRACT
Background and Aims: Pediatric ulcerative colitis (UC) shares many
features with adult-onset disease but there are some unique
considerations; therefore, therapeutic approaches have to be adapted to
these particular needs. We aimed to formulate guidelines for managing
UC in children based on a systematic review (SR) of the literature and
a robust consensus process. The present article is a product of a joint
effort of the European Crohns and Colitis Organization (ECCO) and
the European Society for Paediatric Gastroenterology, Hepatology, and
Nutrition (ESPGHAN).
Methods: A group of 27 experts in pediatric IBD participated in an
iterative consensus process including 2 face-to-face meetings, following
an open call to ESPGHAN and ECCO members. A list of 23 predefined
340
JPGN Volume 55, Number 3, September 2012
Copyright 2012 by ESPGHAN and NASPGHAN. Unauthorized reproduction of this article is prohibited.
JPGN
METHODS
A list of 23 questions addressing the management of UC
in children was first developed, each appraised independently based
on review of the evidence by 2 group members (Appendix 1).
The subgroups recommendations were iterated by e-mail with
the steering committee until refined. The review of the evidence
included both pediatric and adult data because pediatric data were
often scarce (12). Electronic searches were performed in early 2011
using MEDLINE, Embase, CINAHL, and the Cochrane Controlled
Trials Register, and updated in early 2012. The search strategies
used are available upon request. Clinical guidelines, SRs, clinical
trials, cohort studies, case-control studies, diagnostic studies,
surveys, letters, narrative reviews, and case series were used.
The grading of evidence was performed according to the Oxford
Centre for Evidence-based Medicine (Appendix 2).
www.jpgn.org
341
Copyright 2012 by ESPGHAN and NASPGHAN. Unauthorized reproduction of this article is prohibited.
Turner et al
JPGN
Clinical presentation
Investigation
Vasculitis (rare)
Immunodeficiency
states (rare)
CGD chronic granulomatous disease; CVID common variable immune deficiency; NBT nitroblue-tetrazolium test; UC ulcerative colitis.
342
and
Predicting
Disease
Activity
(96%
Practice Points:
1. Achieving complete remission is associated with improved
long-term outcomes; however, there is no evidence to
suggest that endoscopic verification of mucosal healing is
significantly superior to clinical judgment of remission for
this purpose.
2. The Pediatric Ulcerative Colitis Activity Index (PUCAI;
Appendix 3) is a validated score of clinical disease activity
that does not include endoscopy or laboratory markers
and is easy to perform on a daily basis. Generally, a
PUCAI < 10 indicates remission, 10 to 34 mild disease activity,
35 to 64 moderate, and 65 points severe. A clinically
significant response is indicated by a drop in PUCAI of at least
20 points. In practice, clinicians may benchmark their decision
on response by these general cutoff values, but these can vary
individually.
3. In drug trials, the PUCAI score can be used as a noninvasive
primary outcome measure that has proven to be a valid and
responsive index, including high correlation with colonoscopy.
4. Before management changes in active disease, it must be
ensured that symptoms are the result of disease activity
and not of other clinical problems such as irritable bowel
syndrome [IBS], dysmotility, bacterial overgrowth, disease
complications (eg, stenosis), celiac, 5-aminosalicylic acid (5ASA) intolerance, or infection with C difficile or cytomegalovirus [CMV].
5. Complete blood cell count (CBC), albumin, liver enzymes,
and inflammatory markers should be performed periodically.
www.jpgn.org
Copyright 2012 by ESPGHAN and NASPGHAN. Unauthorized reproduction of this article is prohibited.
JPGN
MEDICAL MANAGEMENT
Oral 5-ASA and Rectal Therapy (93% consensus)
1. Oral 5-ASA regimens are recommended as first-line
induction therapy for mild to moderately active pediatric
UC [EL2b, RG B; adults EL1b, RG A] and for maintenance
of remission [EL5, RG D; adults EL1a, RG A] regardless of
other initial treatments
2. Monotherapy with topical 5-ASA may be effective
in selected children with mild to moderate proctitis;
however, this is a rare pediatric phenotype [EL 2b, RG
B; adults E1b, RG A]
3. Combining oral 5-ASA with topical 5-ASA is more effective than oral alone [EL5, RG D; adults EL1b, RG B].
Therefore, whenever tolerated, 5-ASA enemas (or rectal
steroids if 5-ASA is not tolerated) should be offered along
with oral therapy for induction of remission even in
extensive disease [EL5, RG D; adults EL1a, RG A]
4. Rectal 5-ASA is superior and should be preferred over
rectal steroid therapy [EL2b, RG B; adults EL1a, RG A]
Practice Points:
1. There is no evidence that any delivery system of mesalazine
(controlled release and pH dependent) is superior to the other.
2. Mesalazine and sulfasalazine are the 5-ASAs of choice. Oral
mesalazine is dosed 60 to 80 mg kg1 day1 in 2 daily doses up
to 4.8 g daily. Although not evidence based, doses of 100 mg/kg
are sometimes used. Rectal 5-ASA is dosed 25 mg/kg up to 1 g
once daily. Sulfasalazine is dosed 40 to 70 mg kg1 day1 oral
in 2 divided doses with a maximal dose of 4 g/day, and again,
higher doses are in use. The maximal combined oral and rectal
dose should not usually exceed the standard oral dose by >50% or
6.4 g/day in adults.
3. Although pediatric data are lacking, there are several adult trials
showing that once-daily dosing of 5-ASA is equally effective as
twice daily.
4. The maintenance dose should be similar to the dose used
for induction therapy, but lower doses may be considered after
a period of sustained remission (not lower than 40 mg/kg or
2.4 g/day; the minimum effective dose in adults is 1.2 g/day).
5. There is no firm evidence to support the superiority of
sulfasalazine over mesalazine. Sulfasalazine may be particularly helpful in patients with associated arthropathy; it is
considerably less expensive and is the only formulation
available in liquid form. It is, however, associated with
more adverse effects. Gradual dose increase of sulfasalazine
343
Copyright 2012 by ESPGHAN and NASPGHAN. Unauthorized reproduction of this article is prohibited.
Turner et al
6.
7.
8.
9.
344
JPGN
Copyright 2012 by ESPGHAN and NASPGHAN. Unauthorized reproduction of this article is prohibited.
JPGN
Practice Points:
1. Efficacy of probiotics in pediatric and adult UC trials has been
demonstrated for VSL#3 (Table 3 for daily dosing) and
Escherichia coli Nissle.
2. Probiotics should be used with caution in severely immunocompromised patients or those with intravenous catheters
because sepsis has been reported. Bloating, flatulence, and
nausea may be associated with VSL#3.
There have been no controlled trials of adjunctive antibiotics
to induce or maintain remission in pediatric UC, but several
small adult studies suggested some benefit with differing regimens.
Oral tobramycin (107,108), oral rifaximin (109), and a combination
regimen of oral amoxicillin, metronidazole, and tetracycline
(110) had an adjunctive effect to successfully induce remission
in ambulatory adults with UC. Ciprofloxacin (<14 days) did
not induce remission in adults with mild to severe UC (111), but
6-month treatment seemed beneficial in maintaining remission in
adults with moderate to severe disease (112). Rifaximin increased
the remission rate in a small retrospective study of 11 children
(113).
345
Copyright 2012 by ESPGHAN and NASPGHAN. Unauthorized reproduction of this article is prohibited.
Turner et al
JPGN
60
50
45
40
35
30
25
20
15
Week 2
Week 3
Week 4
Week 5
Week 6
Week 7
Week 8
Week 9
Week 10
Week 11
50
40
40
40
35
30
25
20
15
40
40
40
30
30
30
25
20
15
35
35
35
30
30
25
20
15
12.5
30
30
30
25
25
20
20
15
10
25
25
25
25
20
15
15
12.5
10
20
20
20
20
15
15
15
10
7.5
15
15
15
15
15
10
10
7.5
7.5
10
10
10
10
10
10
5
5
5
5
5
5
5
5
5
5
2.5
2.5
0
0
0
0
0
0
0
0
0
First 2 to 3 weeks: Start prednisone at 1 mg/kg up to 40 mg once daily ( after discharge from acute severe colitis admission, the dose may be as high as
60 mg/day). If there is no significant clinical improvement in patients with moderate to severe colitis (ie, PUCAI decrease in <20 points) after 7 to 14 days, or an
increase in PUCAI 20 points at any time, then consider treatment escalation after excluding other causes for steroid-refractory disease (see text).
After the first 2 to 3 weeks: PUCAI 15 to 30: consider keeping the dose stable (while prolonging the total course by 1 week); PUCAI > 35, increase steroids to
the dose of the previous 1 to 2 steps for 1 week and then start weaning again more slowly; PUCAI > 60 or increase in PUCAI by at least 20 points at any time,
consider treatment escalation. In any case, avoid steroid dependency by timely escalation of maintenance therapy.
The risk for exacerbation is smaller with prednisone doses >20 mg, but the risk for adverse events is then higher. Thus, tapering should be instituted early
with larger decrements initially and slower decrements at lower doses. Shortening each stage from 7 to 5 days may be considered in selected cases. With lower
doses, alternate-day treatment may reduce the risk of adverse events. Consider the possibility of adrenal insufficiency, even many months after tapering off
steroids.
Weight, kg
46
79
1114
1517
1723
2433
3453
5466
346
Practice Points:
1. The therapeutic effect of thiopurines may take up to 10 to
14 weeks after the start of treatment.
2. The dose may be adjusted to approximately 2.5 mg/kg of
azathioprine and 1 to 1.5 mg/kg of mercaptopurine, in a single
daily dose.
www.jpgn.org
Copyright 2012 by ESPGHAN and NASPGHAN. Unauthorized reproduction of this article is prohibited.
JPGN
347
Copyright 2012 by ESPGHAN and NASPGHAN. Unauthorized reproduction of this article is prohibited.
Turner et al
(of whom 28 intolerant or refractory to thiopurines) treated
with intramuscular methotrexate at a mean dose of 13.7 3.6
mg m1 week1 (158). Two prospective placebo-controlled
studies regarding the efficacy of methotrexate in adult patients
with UC are under way.
Oral tacrolimus seems to achieve a short-term success
rate (ie, avoidance of colectomy) in the range of 60% to 80% in
pediatric acute severe colitis (159). Oral administration of
tacrolimus in an ambulatory child without acute severe colitis
seems to have steroid-sparing effects in steroid dependency
(160), but more studies are warranted. Oral tacrolimus is typically
used as a bridge to thiopurine therapy owing to its rapid onset of
action, and discontinued after 3 to 5 months to minimize adverse
effects (161).
Biological Agents (93% consensus)
1. Infliximab should be considered for treatment of
children with persistently active, or steroid-dependent
UC, uncontrolled by 5-ASA and thiopurines [EL1b, RG B;
adults EL1b, RG B]
2. Infliximab may be considered for steroid-refractory
(whether oral or intravenous) disease. If infliximab has
been initiated during an acute episode in a thiopurinenave patient, then it can be used as a bridge to thiopurine. In that case, infliximab may be discontinued after
approximately 4 to 8 months [EL4, RG C; adults EL1b,
RG B]
3. Adalimumab should only be used in those who lost
response or were intolerant of infliximab [EL4, RG C;
adults EL1b, RG B]
Practice Points:
1. Infliximab is presently the first-line biological agent in pediatric
UC and should be administered at 5 mg/kg (3 induction
doses >6 weeks followed by 5 mg/kg every 8 weeks for
maintenance); individualization of dosing may be needed.
2. Measuring infliximab levels and antibodies to infliximab can
optimize treatment when failing to maintain remission. If there
are low levels and negative antibodies, then dose escalation
may be indicated. Undetectable infliximab levels in the
presence of antibodies may indicate loss of response and the
need for dose escalation or switching to a different drug.
Normal infliximab level suggests primary nonresponse or
an alternative diagnosis as a cause of symptoms (as outlined
above).
3. Extrapolating from the adult literature and pediatric case series,
adalimumab should be started at 100 mg/m2 up to 160 mg,
followed by 50 mg/m2 up to 80 mg after 2 weeks and then
25 mg/m2 up to 40 mg every other week; dose individualization
may be needed.
4. There is no good evidence to support combining infliximab
with thiopurines in children with UC who failed thiopurine
treatment. Biological agents are, however, used by some
pediatric gastroenterologists in combination with thiopurines
for at least the first 4 to 8 months of therapy, even if the child
has been a nonresponder to thiopurines. The balance of safety
versus benefits of combination treatment needs to be fully
explained.
5. It is unknown whether 5-ASA offers an advantage in
combination with biological agents, but given the potential
benefit (including possible cancer chemoprevention) and the
348
JPGN
Copyright 2012 by ESPGHAN and NASPGHAN. Unauthorized reproduction of this article is prohibited.
JPGN
SURGICAL CONSIDERATIONS
Elective Surgery for Pediatric UC (96% consensus)
1. Elective colectomy may be indicated in children with
active or steroid-dependent UC despite maximal treatment with 5-ASA, thiopurines, and anti-TNF therapy, or
the finding of colonic dysplasia [EL5, RG D; adults EL 4,
RG C]
2. In general, restorative proctocolectomy (ileoanal pouch
or ileal pouch-anal anastomosis), especially the J-pouch,
is preferred over straight pull-through (ileoanal) or
ileorectal anastomosis for elective surgery of pediatric
UC [EL2b, RG B]
3. The laparoscopic surgical approach can be used safely
in children with low complication rates and superior
cosmetic results [EL2b, RG B]
Practice Points:
1. The disease should be reevaluated thoroughly before referral to
colectomy, including repeated ileocolonoscopy and ruling out
other causes for the symptoms.
2. The role of ileorectal anastomosis is controversial but may be
considered in girls who are primarily concerned about the
reduced fecundity associated with restorative proctocolectomy.
High early failure rates have been reported and a lifelong
follow-up of the retained rectal stump is required.
3. A 2-stage operation (colectomy and pouch formation with
ileostomy in the first stage, and closure of the stoma at the
second stage) is the most common approach for elective surgery
for UC. A 3-stage operation (ie, splitting the first operation into
colectomy first and then pouch formation) should be considered
in patients with high-dose steroids or those experiencing
severe malnutrition, and when the diagnosis of CD has not been
excluded completely.
4. Restorative proctocolectomy without protecting ileostomy
(ie, 1-stage operation) may be safe in selected children without
any risk factors (eg, high-dose steroids). Anticipated tension at
the anastomosis site precludes this option.
5. There is no need for preoperative bowel preparation.
6. Preoperative high-dose steroids and questionably infliximab are
associated with increased surgical complications; thiopurines or
calcineurin inhibitors are probably not.
7. The risks of thromboembolic complications are low in
ambulatory pediatric patients with UC, and routine thromboembolic prophylaxis cannot be recommended.
Colectomy should be discussed as a viable alternative in
children who experience ongoing symptoms despite multiple
349
Copyright 2012 by ESPGHAN and NASPGHAN. Unauthorized reproduction of this article is prohibited.
Turner et al
immunosuppressive medications, especially if steroid dependent.
The most frequent indication for colectomy in ambulatory children
with UC is a chronic ongoing disease, at times steroid dependent; in
adults, dysplasia is also a common indication (191). In general,
effective doses of immunomodulatory agents and infliximab should
be attempted in most cases before referral to colectomy in ambulatory mild to moderate UC. In those losing response to infliximab,
adalimumab may be considered before colectomy.
Most pediatric surgeons treating patients with UC prefer
pouch surgery over straight pull-through, but there are few pediatric
data to support this. Most series report better continence after the
pouch procedure. A pediatric meta-analysis consisting of 5 studies
and 306 patients suggested that the straight ileoanal pull-through
was associated with a higher failure risk (15% for straight pullthrough vs 8% for pouch procedure), and perianal sepsis (20%
vs 10%), as well as a higher stool frequency (OR 2.63, 95% CI
1.343.92) (192). A multicenter study including 112 children with
straight ileoanal pull-through and 91 with a J-pouch showed similar
early and late complication rates (193). Stool frequency was higher
in the straight pull-through group, although the difference became
less apparent with longer follow-up (mean daily stool frequency at
24 months: 6.2 for the pouch procedure vs 8.4 for the straight pullthrough). Because the quality of life in children with restorative
proctocolectomy is inversely related to stool frequency and
continence (194), this difference is clinically important; however,
the pouch procedure is associated with risk for pouchitis
(see below).
A 2-stage operation is favored by most pediatric surgeons in
elective colectomy (192). One-stage repair may be feasible in
selected children with low disease activity, good nutritional status,
and not treated with steroids but it is associated with an increased
complication rate (195,196). A 3-stage surgery is performed
mainly in patients who require emergency colectomy for refractory
acute severe attack or in malnourished patients and those treated
with high-dose corticosteroids. With any chosen procedure,
a laparoscopic-assisted procedure is feasible and safe in adults
(197,198) and in children (199,200).
Ileorectal anastomosis is not often performed. Earlier
reports showed high failure rates, and there is a lifelong need for
endoscopic surveillance of the rectal stump. Adult studies have
shown that in selected cases, ileorectal anastomosis is safe, with
better continence function than pouch formation (201); however,
there was a higher urgency rate; the quality of life was similar and
approximately half required resection of the rectum in 20 years.
Nonetheless, this surgery may be considered, especially in young
female patients considering future fecundity. In a meta-analysis the
risk of female infertility was increased from 15% among 411 girls
with UC without ileal pouch-anal anastomosis (IPAA) to 48% in
481 girls after IPAA (202,203). It should be emphasized that
many of the infertile cases will eventually achieve pregnancy
with supportive treatments. It is unlikely that there would be a
difference in fertility problems between straight pull-through and
pouch procedures because the degree of pelvic dissection is similar;
however, fecundity is probably better preserved after ileorectal
anastomosis (204). An open discussion with a girl requiring
colectomy and her caregivers stating the pros and cons of each
procedure is mandatory before any surgical intervention.
Preoperative steroid therapy (>20 mg in adults), hypoalbuminemia, and malnutrition are associated with increased
surgical complication rates (205), but waiting for the reversal of
their effects before surgery is not recommended in the acute setting
(206). A meta-analysis of 5 studies found a higher postoperative
short-term complication rate in 706 adults treated with infliximab
before colectomy (207). In a population-based case-control study,
the risk of venous thromboembolic events in UC was increased
350
JPGN
across all age groups, but the absolute rate was much higher in the
older population (27 deep vein thrombosis [DVT] cases per 10,000
person-years in the 0- to 20-year-old group (odds ratio 10 [95% CI
3.429.3]) vs 207/10,000 in the older than 60-years-old group
(208)).
Pouchitis (100% consensus)
1. When pouchitis is suspected for the first time, endoscopy
with mucosal biopsies should be performed to confirm
the diagnosis [EL3b, RG C; adults EL3a, RG B]
2. The first-line therapy of pouchitis should be a 14-day
course of antibiotics; ciprofloxacin seems to be more
effective than metronidazole [EL5, RG C; adults EL1b,
RG A]; in persistent cases, combined metronidazole and
ciprofloxacin or oral budesonide can be given [EL5, RG
C; adults EL2b, RG B]
3. Probiotics may be used for maintaining antibioticinduced remission in recurrent pouchitis [EL5, RG C;
adults EL1b, RG B]
4. Topical mesalazine is an effective treatment for
inflammation of the residual rectal cuff, known as cuffitis
[EL 5, RG D; adults EL4, RGD]
Practice Points:
1. In chronic (>4 weeks) or refractory pouchitis-like symptoms,
other diagnoses should be sought, including cuffitis, missed
CD, anastomotic ulcer, irritable pouch syndrome, infectious
pouchitis, and anastomotic stenosis.
2. Fecal calprotectin can reflect the degree of pouch inflammation.
1
1
3. Metronidazole (2030 mg kg day in 3) divided doses
1
and/or ciprofloxacin (30 mg kg day1 up to 1 g/day in 2
divided doses) for 14 days are common dosing strategies for
pouchitis. Dosing of VSL#3 for recurrent pouchitis in 2 adult
RCT was 1800 billion bacteria once daily (4 sachets of
450 billion bacteria).
4. Although VSL#3 (900 billion bacteria daily) also may be
effective for preventing the first episode of pouchitis, this is not
justified because many children will never develop pouchitis.
5. Immunosupressants or infliximab may be considered in
refractory pouchitis.
Copyright 2012 by ESPGHAN and NASPGHAN. Unauthorized reproduction of this article is prohibited.
JPGN
Practice Points:
1. In children with UC without excessive steroid use, height
velocity is usually normal.
2. Continuation of regular diet is recommended during mild to
moderately active disease.
3. If oral intake is poor because of anorexia in active disease,
enteral nutrition or high-energy supplements may be indicated.
351
Copyright 2012 by ESPGHAN and NASPGHAN. Unauthorized reproduction of this article is prohibited.
Turner et al
4. Patients with UC are much less prone to impaired bone density
compared with patients with CD.
5. Adequate nutrition, weight-bearing exercise, adequate disease
control, avoidance of smoking, and steroid-sparing strategies
should all be used to promote bone health.
Undernutrition and particularly growth failure are less
common in children with UC compared with patients with CD,
but nutritional deficiencies can develop quickly during periods of
active disease (239). In newly diagnosed IBD, low BMI was seen in
8% of children with UC, whereas short stature was noted only in CD
(240). As a rule, children with UC reach their expected adult height
(241,242).
It has been documented that bowel rest or exclusive enteral
nutrition does not have any therapeutic role in acute UC (243245),
although bowel rest can alleviate abdominal pain, when severe.
For pediatric patients, there is a small retrospective study showing
that total parenteral nutrition and bowel rest did not improve the
outcome (246). In a pediatric prospective study, 74 of 128 (58%)
were not eating solid food by the third admission day for acute
severe colitis, but this was not associated with improved outcome
after controlling for disease activity (D.T., unpublished data).
There is no dietary approach proven to reduce the risk of either
developing or preventing a relapse of UC.
Peak bone mass attained during late childhood, adolescence,
and early adulthood is the most important determinant of lifelong skeletal health. Children with IBD are particularly prone
to disturbed bone health because of increased circulating inflammatory cytokines, malnutrition, delayed puberty, decreased
physical activity, treatment with corticosteroids, and in girls,
primary or secondary amenorrhea (247,248). Severe osteopenia
was present in 3% to 6% in UC compared with 12% to 18% in CD
(249251).
According to recently published clinical guidelines, DEXA
is the preferred screening tool for bone density measurement in
children and adolescents, provided that age- and sex-matched
z scores are used (252). Because DEXA measures BMD in 2
dimensions, it is recommended that in children with linear growth
delay (heights z score <2.0) DEXA results should also be adjusted
for height (252). It has been suggested that DEXA should be
performed in all children newly diagnosed as having IBD and
repeated in cases of severe disease course, including suboptimal
growth velocity, prolonged malnutrition, amenorrhea, delayed
puberty, and long or repeated treatments with steroids (252);
however, these recommendations are not evidence based.
Children with IBD are particularly at risk for vitamin D
deficiency, but this was not found to be associated with osteopenia
(253). Therefore, the significance of hypovitaminosis D in young
patients with UC merits further study. Nonetheless, it is widely
accepted that vitamin D levels be routinely measured and treated
when appropriate, especially in children with decreased BMD. Ageappropriate nutrition support, weight-bearing exercise, and adequate disease control using steroid-sparing strategies (248,250,252)
are also advocated to improve bone formation.
Psychosocial Support and Adherence to Therapy (100%
consensus)
1. Psychological intervention should be offered to patients
in need because it improves quality of life (QOL), coping,
and depression (Pediatric EL2b, RG B; Adults EL3b, RG C)
2. Nonadherence to medication should be also considered in
children and adolescents, particularly during unstable
disease course (Pediatric EL3a, RG B; Adults EL2a, RG B)
352
JPGN
Practice Points:
1. Every clinic visit made by children and adolescents with
IBD must include attention to psychological problems as part
of the consultation.
2. Pediatric IBD programs should be ready to offer psychological
interventions according to individual needs and local resources,
involving qualified specialists.
3. Adherence may be evaluated by interviews of both the
adolescent and parents, drug monitoring (eg, thiopurine
metabolite level), and prescription refill rates.
4. Adherence may be improved by providing comprehensive
information regarding the prescribed medication, keeping the
pill burden as low as possible, using single daily dosage when
possible and providing pillboxes.
Several recent SRs, including a Cochrane review, have
concluded that adolescents with IBD, especially boys, have reduced
health-related quality of life, including anxiety, depression, social
problems, and low self-esteem (254257). The problems seem to be
associated with more severe disease course, whereas most children
with mild IBD report psychosocial functioning comparable with
healthy controls (258,259). No evidence exists that psychosocial
problems contribute to the etiology of UC; however, observational
data from primarily the adult literature provide support to the
impression that psychosocial stress is a risk factor for relapse
(217). Certain drugs used for treatment of UC, such as corticosteroids, may induce change in mood and even psychiatric disturbances to which children are particularly sensitive. A Cochrane
review found that psychological interventions resulted in improvements in coping and depression among adolescents (256).
Nonadherence in IBD is an important and frequent problem,
reported in 50% to 66% of children (254,260), especially in
adolescence. The presence of nonadherence is related to increased
disease activity in adolescents (260). Individual studies among
adolescents with IBD have reported barriers identical to those
identified among adults as well as more pediatric-specific barriers:
fear of adverse events of medication, belief that the disease is
inactive, belief that the medication is not working, >1 daily
medication (254), forgetfulness, interference with other activities,
difficulty in swallowing pills (261), lack of motivation, and parent
child conflict (262).
Transitional Care (100% consensus)
1. Every adolescent should be included in transition programs that could be adapted according to the local
organization of pediatric and adult facilities [EL5, RG D]
2. The adolescent should be encouraged to assume increasing responsibility for treatment and to visit the clinic at
least once without being accompanied by the parents
[EL5, RG D]
Practice Points:
1. Whenever feasible, at least 1 joint clinic in which the adolescent
is seen by both a pediatric and an adult gastroenterologist
is recommended.
2. The time of transition should be individually adapted according
to psychosocial readiness. Most adolescents will benefit from a
transition program during the 16- to 18-year-old age period.
Pediatric IBD services differ from those for adults. Children
are usually offered endoscopy under general anesthesia and are
www.jpgn.org
Copyright 2012 by ESPGHAN and NASPGHAN. Unauthorized reproduction of this article is prohibited.
JPGN
Induction of remission
Mild disease (PUCAI 10-35)
Systemically ill
Oral 5-ASA at maximal dose3;
Enemas should be offered and may
be sufficient in proctitis4
No sufficient response
in 7-14 days
Prednisone 1 mg/kg
once daily up to 40 mg +
5-ASA3, 4
No sufficient
response
Sufficient response
No sufficient
in 7-14 days
response in 7-14
Taper corticosteroids
over 10 weeks5
No sufficient response
7
Sufficient response
Maintenance of remission
5-ASA for all patients3; Probiotics may be added. Rectal therapy4 may be sufficient in proctitis
Stepping down10
If disease is chronically active, or X2-3 annual flares, or severe attack while on 5-ASA, add thiopurines
(azathioprine 2-2.5 mg/kg once daily or mercaptopurine 1.5 mg/kg once daily)9
Stepping down10
If disease is still chronically active or frequent flares despite adequate thiopurine treatment, consider infliximab
therapy (or adalimumab in cases of failure with infliximab)11
If biologic therapy fails (including dose intensification) and other diagnosis ruled out1 consider colectomy.
Apharesis may be attempted in very selected children when applicable
FIGURE 1. Joint European Society for Paediatric Gastroenterology, Hepatology and Nutrition (ESPGHAN)-European Crohns and Colitis Organization
(ECCO) therapeutic paradigm for pediatric ulcerative colitis (UC). Medical therapies in UC should be divided into those that induce remission (5aminosalicylic acid [5-ASA], corticosteroids, anti-tumor necrosis factor [TNF] therapy, calcineurin inhibitors, and likely probiotics), and those that maintain
remission (5-ASA, thiopurines, anti-TNF therapy, and selected probiotics). 1In any state of active disease, the following must be ruled out: infectious colitis
(including cytomegalovirus [CMV] and C difficile), 5-ASA-related colitis, lactose intolerance, irritable bowel syndrome, wrong diagnosis, celiac disease, and
the like. 2Unlike in adults, endoscopic evaluation of the rectal mucosa is conceived to be more invasive for routine monitoring of disease activity and
response to therapy in children. Therefore, these should be based on noninvasive indirect markers of disease activity. Cutoff values of the Pediatric UC
Activity Index (PUCAI) for remission, mild, moderate, and severe disease activity have been previously validated in 3 independent cohorts. 35-ASA is dosed
60 to 80 mg kg1 day1 up to 4.8 g daily. In clinical practice, higher doses of up to 100 mg/kg are often used effectively but without strong supporting
evidence. Recent data in adults suggest that once-daily 3 g 5-ASA is at least as effective as twice-daily dosing. 45-ASA enemas (25 mg/kg up to 1 g) are more
effective than steroid enemas. Enemas should be administered in the left decubitus position. Liquid enemas are more difficult to tolerate than foams and
suppositories but work for more extensive colitis. 5If there is lack of improvement (ie, PUCAI decrease of <20 points) after 7 to 10 days or an increase in
PUCAI 20 points at any time, consider admission for intravenous steroids or outpatient treatment with anti-TNF therapy, or less often tacrolimus. Steroid
dependency should be declared in children achieving remission with corticosteroids but who experience return of symptoms when dosage is lowered or
within 3 months following complete taper, or if steroids cannot be stopped within 14 to 16 weeks. Maintenance therapy should be then escalated. 6Turner
et al (11) 7Response is defined as a drop in PUCAI of at least 20 points; however, the goal of induction therapy is eventually complete clinical remission
(PUCAI<10). 8For example, previous intolerance or resistance to steroids, or when infliximab is indicated anyway for maintenance treatment after failing
thiopurines. 9Measuring thiopurine methyltransferase (genotyping or enzymatic activity) at baseline, and 6-TG and 6-MMP levels after 2 to 3 months, may
aid in optimizing thiopurine dosing. 10If infliximab has been used in thiopurine-nave disease, thiopurines may be added and infliximab discontinued after
4 to 8 months if complete remission has been achieved. Stepping down to 5-ASA may be considered in selected cases, if 5-ASA did not fail previously, and
after a period of sustained complete remission. 11There is no evidence to support adding thiopurines to infliximab in thiopurine-failure children; however,
some discontinue thiopurines after 4 to 8 months of combined therapy.
www.jpgn.org
353
Copyright 2012 by ESPGHAN and NASPGHAN. Unauthorized reproduction of this article is prohibited.
Turner et al
JPGN
354
QUALIFYING STATEMENT
These guidelines may be revised as necessary to account for
changes in technology, new data, or other aspects of clinical
practice. These guidelines are intended to be an educational device
to provide information that may assist clinicians in providing care to
patients. These guidelines are not a rule and should not be construed
as establishing a legal standard of care or as encouraging, advocating, requiring, or discouraging any particular treatment. Clinical
decisions in any particular case involve a complex analysis of the
patients condition and available courses of action. Therefore,
clinical considerations may require taking a course of action that
varies from these guidelines.
REFERENCES
1. Benchimol EI, Fortinsky KJ, Gozdyra P, et al. Epidemiology
of pediatric inflammatory bowel disease: a systematic review of
international trends. Inflamm Bowel Dis 2011;17:42339.
2. Henderson P, Hansen R, Cameron FL, et al. Rising incidence of
pediatric inflammatory bowel disease in Scotland. Inflamm Bowel
Dis 2012;18:9991005.
3. Heyman MB, Kirschner BS, Gold BD, et al. Children with earlyonset inflammatory bowel disease (IBD): analysis of a pediatric IBD
consortium registry. J Pediatr 2005;146:3540.
4. Van Limbergen J, Russell RK, Drummond HE, et al. Definition
of phenotypic characteristics of childhood-onset inflammatory bowel
disease. Gastroenterology 2008;135:111422.
5. Gower-Rousseau C, Dauchet L, Vernier-Massouille G, et al. The
natural history of pediatric ulcerative colitis: a population-based cohort
study. Am J Gastroenterol 2009;104:20808.
6. Langholz E, Munkholm P, Krasilnikoff PA, et al. Inflammatory bowel
diseases with onset in childhood. Clinical features, morbidity, and
mortality in a regional cohort. Scand J Gastroenterol 1997;32:13947.
7. Jakobsen C, Bartek J Jr, Wewer V, et al. Differences in phenotype and
disease course in adult and paediatric inflammatory bowel diseasea
population-based study. Aliment Pharmacol Ther 2011;34:121724.
8. Turner D, Walsh CM, Benchimol EI, et al. Severe paediatric ulcerative
colitis: incidence, outcomes and optimal timing for second-line
therapy. Gut 2008;57:3318.
9. Dinesen LC, Walsh AJ, Protic MN, et al. The pattern and outcome of
acute severe colitis. J Crohns Colitis 2010;4:4317.
10. Travis SPL, Stange EF, Lemann M, et al. European evidence-based
consensus on the management of ulcerative colitis: current management. J Crohn Colitis 2008;2:2462.
11. Turner D, Travis SP, Griffiths AM, et al. Consensus for managing acute
severe ulcerative colitis in children: a systematic review and joint
statement from ECCO, ESPGHAN, and the Porto IBD Working Group
of ESPGHAN. Am J Gastroenterol 2011;106:57488.
12. Wilson DC, Thomas AG, Croft NM, et al. Systematic review of the
evidence base for the medical treatment of paediatric inflammatory
bowel disease. J Pediatr Gastroenterol Nutr 2010;50:S1434.
13. IBD Working Group of the European Society for Paediatric Gastroenterology Hepatology and Nutrition. Inflammatory bowel disease in
children and adolescents: recommendations for diagnosisthe Porto
criteria. J Pediatr Gastroenterol Nutr. 2005;41:17.
14. Levine A, Griffiths A, Markowitz J, et al. Pediatric modification of
the Montreal classification for inflammatory bowel disease: the Paris
classification. Inflamm Bowel Dis 2011;17:131421.
www.jpgn.org
Copyright 2012 by ESPGHAN and NASPGHAN. Unauthorized reproduction of this article is prohibited.
JPGN
15. Bousvaros A, Antonioli DA, Colletti RB, et al. Differentiating ulcerative colitis from Crohn disease in children and young adults: report of a
working group of the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition and the Crohns and Colitis
Foundation of America. J Pediatr Gastroenterol Nutr 2007;44:
65374.
16. Rajwal SR, Puntis JW, McClean P, et al. Endoscopic rectal sparing in
children with untreated ulcerative colitis. J Pediatr Gastroenterol Nutr
2004;38:669.
17. Glickman JN, Bousvaros A, Farraye FA, et al. Pediatric patients
with untreated ulcerative colitis may present initially with unusual
morphologic findings. Am J Surg Pathol 2004;28:1907.
18. Markowitz J, Kahn E, Grancher K, et al. Atypical rectosigmoid
histology in children with newly diagnosed ulcerative colitis. Am J
Gastroenterol 1993;88:20347.
19. Levine A, de Bie CL, Turner D, et al. Atypical disease phenotypes
in paediatric ulcerative colitis: 5-year analyses of the EUROKIDS
registry. Inflamm Bowel Dis. 2012 May 8. [Epub ahead of print]
20. Robert ME, Tang L, Hao LM, et al. Patterns of inflammation
in mucosal biopsies of ulcerative colitis: perceived differences in
pediatric populations are limited to children younger than 10 years.
Am J Surg Pathol 2004;28:1839.
21. Kim B, Barnett JL, Kleer CG, et al. Endoscopic and histological
patchiness in treated ulcerative colitis. Am J Gastroenterol 1999;94:
325862.
22. Haskell H, Andrews CW Jr, Reddy SI, et al. Pathologic features and
clinical significance of backwash ileitis in ulcerative colitis. Am J
Surg Pathol 2005;29:147281.
23. Tobin JM, Sinha B, Ramani P, et al. Upper gastrointestinal mucosal
disease in pediatric Crohn disease and ulcerative colitis: a blinded,
controlled study. J Pediatr Gastroenterol Nutr 2001;32:4438.
24. de Bie CI, Buderus S, Sandhu BK, et al. Diagnostic workup of
paediatric patients with inflammatory bowel disease in Europe: results
of a 5-year audit of the EUROKIDS registry. J Pediatr Gastroenterol
Nutr 2012;54:37480.
25. Koletzko S, Niggemann B, Arato A, et al. Diagnostic approach and
management of cows milk protein allergy in infants and children:
a practical guideline of the GI-committee of ESPGHAN. J Pediatr
Gastroenterol Nutr. 2012;55:221229.
26. Glocker EO, Frede N, Perro M, et al. Infant colitisits in the genes.
Lancet 2010;376:1272.
27. Glocker EO, Kotlarz D, Boztug K, et al. Inflammatory bowel disease
and mutations affecting the interleukin-10 receptor. N Engl J Med
2009;361:203345.
28. Begue B, Verdier J, Rieux-Laucat F, et al. Defective IL10 signaling
defining a subgroup of patients with inflammatory bowel disease. Am J
Gastroenterol 2011;106:154455.
29. Stange EF, Travis SP, Vermeire S, et al. European evidence-based
consensus on the diagnosis and management of ulcerative colitis:
definitions and diagnosis. J Crohns Colitis 2008;2:123.
30. Travis SP, Schnell D, Krzeski P, et al. Developing an instrument to
assess the endoscopic severity of ulcerative colitis: the Ulcerative
Colitis Endoscopic Index of Severity (UCEIS). Gut 2012;61:53542.
31. Beattie RM, Nicholls SW, Domizio P, et al. Endoscopic assessment of
the colonic response to corticosteroids in children with ulcerative
colitis. J Pediatr Gastroenterol Nutr 1996;22:3739.
32. Colombel JF, Rutgeerts P, Reinisch W, et al. Early mucosal healing
with infliximab is associated with improved long-term clinical outcomes in ulcerative colitis. Gastroenterology 2011;141:1194201.
33. Gustavsson A, Jarnerot G, Hertervig E, et al. Clinical trial: colectomy
after rescue therapy in ulcerative colitis3-year follow-up of the
Swedish-Danish controlled infliximab study. Aliment Pharmacol Ther
2010;32:9849.
34. Froslie KF, Jahnsen J, Moum BA, et al. Mucosal healing in inflammatory bowel disease: results from a Norwegian population-based
cohort. Gastroenterology 2007;133:41222.
35. Gustavsson A, Jarnerot G, Hertervig E, et al. A 2-year follow-up of the
Swedish-Danish Infliximab/placebo trial in steroid resistant acute
ulcerative colitis. Gastroenterology 2007;132:A983.
36. Turner D, Mack D, Leleiko N, et al. Severe pediatric ulcerative
colitis: a prospective multicenter study of outcomes and predictors
of response. Gastroenterology 2010;138:228291.
www.jpgn.org
355
Copyright 2012 by ESPGHAN and NASPGHAN. Unauthorized reproduction of this article is prohibited.
Turner et al
59. Romano C, Famiani A, Comito D, et al. Oral beclomethasone
dipropionate in pediatric active ulcerative colitis: a comparison trial
with mesalazine. J Pediatr Gastroenterol Nutr 2010;50:3859.
60. Quiros JA, Heyman MB, Pohl JF, et al. Safety, efficacy, and pharmacokinetics of balsalazide in pediatric patients with mild-to-moderate
active ulcerative colitis: results of a randomized, double-blind study.
J Pediatr Gastroenterol Nutr 2009;49:5719.
61. Ferry GD, Kirschner BS, Grand RJ, et al. Olsalazine versus
sulfasalazine in mild to moderate childhood ulcerative colitis: results
of the Pediatric Gastroenterology Collaborative Research Group
Clinical Trial. J Pediatr Gastroenterol Nutr 1993;17:328.
62. Heyman MB, Kierkus J, Spenard J, et al. Efficacy and safety of
mesalamine suppositories for treatment of ulcerative proctitis in
children and adolescents. Inflamm Bowel Dis 2010;16:19319.
63. Christensen LA, Fallingborg J, Jacobsen BA, et al. Bioavailability of
5-aminosalicyclic acid from slow release 5-aminosalicyclic acid drug
and sulfasalazine in normal children. Dig Dis Sci 1993;38:18316.
64. Barden L, Lipson A, Pert P, et al. Mesalazine in childhood inflammatory bowel disease. Aliment Pharmacol Ther 1989;3:597603.
65. Tolia V, Massoud N, Klotz U. Oral 5-aminosalicyclic acid in children
with colonic chronic inflammatory bowel disease: clinical and pharmacokinetic experience. J Pediatr Gastroenterol Nutr 1989;8:3338.
66. Nikfar S, Rahimi R, Rezaie A, et al. A meta-analysis of the efficacy of
sulfasalazine in comparison with 5-aminosalicylates in the induction
of improvement and maintenance of remission in patients with
ulcerative colitis. Dig Dis Sci 2009;54:115770.
67. Wiersma H, Escher JC, Dilger K, et al. Pharmacokinetics of
mesalazine pellets in children with inflammatory bowel disease.
Inflamm Bowel Dis 2004;10:62631.
68. Paoluzi OA, Iacopini F, Pica R, et al. Comparison of two different daily
dosages (2.4 vs. 1.2 g) of oral mesalazine in maintenance of remission
in ulcerative colitis patients: 1-year follow-up study. Aliment Pharmacol Ther 2005;21:11119.
69. Sandborn WJ, Regula J, Feagan BG, et al. Delayed-release oral
mesalamine 4.8 g/day (800-mg tablet) is effective for patients
with moderately active ulcerative colitis. Gastroenterology 2009;
137:193443.
70. Hanauer SB, Sandborn WJ, Kornbluth A, et al. Delayed-release
oral mesalamine at 4.8 g/day (800 mg tablet) for the treatment of
moderately active ulcerative colitis: the ASCEND II trial. Am J
Gastroenterol 2005;100:247885.
71. Hanauer SB, Sandborn WJ, Dallaire C, et al. Delayed-release oral
mesalamine 4.8 g/day (800 mg tablets) compared to 2.4 g/day (400 mg
tablets) for the treatment of mildly to moderately active ulcerative
colitis: the ASCEND I trial. Can J Gastroenterol 2007;21:82734.
72. Kruis W, Kiudelis G, Racz I, et al. Once daily versus three times daily
mesalazine granules in active ulcerative colitis: a double-blind, doubledummy, randomised, non-inferiority trial. Gut 2009;58:23340.
73. Williams C, Panaccione R, Ghosh S, et al. Optimizing clinical use of
mesalazine (5-aminosalicylic acid) in inflammatory bowel disease.
Therap Adv Gastroenterol 2011;4:23748.
74. Kamm MA, Lichtenstein GR, Sandborn WJ, et al. Randomised trial of
once- or twice-daily MMX mesalazine for maintenance of remission in
ulcerative colitis. Gut 2008;57:893902.
75. Ford AC, Khan KJ, Sandborn WJ, et al. Once-daily dosing vs.
conventional dosing schedule of mesalamine and relapse of quiescent
ulcerative colitis: systematic review and meta-analysis. Am J Gastroenterol 2011;106:20707.
76. Loftus EV Jr, Kane SV, Bjorkman D. Systematic review: short-term
adverse effects of 5-aminosalicylic acid agents in the treatment of
ulcerative colitis. Aliment Pharmacol Ther 2004;19:17989.
77. Arend LJ, Springate JE. Interstitial nephritis from mesalazine: case
report and literature review. Pediatr Nephrol 2004;19:5503.
78. Kohli R, Melin-Aldana H, Sentongo TA. Mesalamine-induced
pneumonitis during therapy for chronic inflammatory bowel disease:
a pediatric case report. J Pediatr Gastroenterol Nutr 2005;41:47982.
79. Sentongo TA, Piccoli DA. Recurrent pericarditis due to mesalamine
hypersensitivity: a pediatric case report and review of the literature.
J Pediatr Gastroenterol Nutr 1998;27:3447.
80. Selhub J, Dhar GJ, Rosenberg IH. Inhibition of folate enzymes by
sulfasalazine. J Clin Invest 1978;61:2214.
356
JPGN
81. Marshall JK, Irvine EJ. Rectal aminosalicylate therapy for distal
ulcerative colitis: a meta-analysis. Aliment Pharmacol Ther 1995;9:
293300.
82. Cortot A, Maetz D, Degoutte E, et al. Mesalamine foam enema versus
mesalamine liquid enema in active left-sided ulcerative colitis. Am J
Gastroenterol 2008;103:310614.
83. Malchow H, Gertz B. A new mesalazine foam enema (Claversal foam)
compared with a standard liquid enema in patients with active distal
ulcerative colitis. Aliment Pharmacol Ther 2002;16:41523.
84. Gionchetti P, Ardizzone S, Benvenuti ME, et al. A new mesalazine gel
enema in the treatment of left-sided ulcerative colitis: a randomized
controlled multicentre trial. Aliment Pharmacol Ther 1999;13:3818.
85. dAlbasio G, Paoluzi P, Campieri M, et al. Maintenance treatment of
ulcerative proctitis with mesalazine suppositories: a double-blind
placebo-controlled trial. The Italian IBD Study Group. Am J Gastroenterol 1998;93:799803.
86. Hanauer S, Good LI, Goodman MW, et al. Long-term use of
mesalamine (Rowasa) suppositories in remission maintenance of
ulcerative proctitis. Am J Gastroenterol 2000;95:174954.
87. Marteau P, Crand J, Foucault M, et al. Use of mesalazine slow release
suppositories 1 g three times per week to maintain remission of
ulcerative proctitis: a randomised double blind placebo controlled
multicentre study. Gut 1998;42:1959.
88. Odera G, Giuliani B, Santini B, et al. Topical treatment with 5-ASA
and hydrocortisone. Riv Ital Pediatr 1986;12:6748.
89. Marshall JK, Thabane M, Steinhart AH, et al. Rectal 5-aminosalicylic
acid for induction of remission in ulcerative colitis. Cochrane Database Syst Rev 2010;CD004115.
90. Cohen RD, Woseth DM, Thisted RA, et al. A meta-analysis and
overview of the literature on treatment options for left-sided ulcerative
colitis and ulcerative proctitis. Am J Gastroenterol 2000;95:126376.
91. Regueiro M, Loftus EV Jr, Steinhart AH, et al. Medical management
of left-sided ulcerative colitis and ulcerative proctitis: critical evaluation of therapeutic trials. Inflamm Bowel Dis 2006;12:97994.
92. Lamet M, Ptak T, Dallaire C, et al. Efficacy and safety of mesalamine
1 g HS versus 500 mg BID suppositories in mild to moderate ulcerative
proctitis: a multicenter randomized study. Inflamm Bowel Dis 2005;11:
62530.
93. Lamet M. A multicenter, randomized study to evaluate the efficacy and
safety of mesalamine suppositories 1 g at bedtime and 500 mg twice
daily in patients with active mild-to-moderate ulcerative proctitis.
Digest Dis Sci 2011;56:51322.
94. Ford AC, Khan KJ, Sandborn WJ, et al. Efficacy of topical 5aminosalicylates in preventing relapse of quiescent ulcerative colitis:
a meta-analysis. Clin Gastroenterol Hepatol 2012;10:5139.
95. Marteau P, Probert CS, Lindgren S, et al. Combined oral and enema
treatment with Pentasa (mesalazine) is superior to oral therapy alone
in patients with extensive mild/moderate active ulcerative colitis: a
randomised, double blind, placebo controlled study. Gut 2005;54:
9605.
96. Yokoyama H, Takagi S, Kuriyama S, et al. Effect of weekend
5-aminosalicylic acid (mesalazine) enema as maintenance therapy
for ulcerative colitis: results from a randomized controlled study.
Inflamm Bowel Dis 2007;13:111520.
97. Hyams J, Markowitz J, Lerer T, et al. The natural history of corticosteroid therapy for ulcerative colitis in children. Clin Gastroenterol
Hepatol 2006;4:111823.
98. Baron JH, Connell AM, Kanaghinis TG, et al. Out-patient treatment of
ulcerative colitis. Comparison between three doses of oral prednisone.
Br Med J 1962;2:4413.
99. Kolho KL, Raivio T, Lindahl H, et al. Fecal calprotectin remains high
during glucocorticoid therapy in children with inflammatory bowel
disease. Scand J Gastroenterol 2006;41:7205.
100. Powell-Tuck J, Bown RL, Lennard-Jones JE. A comparison of
oral prednisolone given as single or multiple daily doses for active
proctocolitis. Scand J Gastroenterol 1978;13:8337.
101. Uchida K, Araki T, Toiyama Y, et al. Preoperative steroid-related
complications in Japanese pediatric patients with ulcerative colitis.
Dis Colon Rectum 2006;49:749.
102. Rizzello F, Gionchetti P, DArienzo A, et al. Oral beclometasone
dipropionate in the treatment of active ulcerative colitis: a double-blind
placebo-controlled study. Aliment Pharmacol Ther 2002;16:110916.
www.jpgn.org
Copyright 2012 by ESPGHAN and NASPGHAN. Unauthorized reproduction of this article is prohibited.
JPGN
103. Manguso F, Balzano A. Meta-analysis: the efficacy of rectal beclomethasone dipropionate vs. 5-aminosalicylic acid in mild to moderate
distal ulcerative colitis. Aliment Pharmacol Ther 2007;26:219.
104. Campieri M, Adamo S, Valpiani D, et al. Oral beclometasone
dipropionate in the treatment of extensive and left-sided active ulcerative colitis: a multicentre randomised study. Aliment Pharmacol Ther
2003;17:147180.
105. DHaens GR, Kovacs A, Vergauwe P, et al. Preliminary efficacy and
safety study of a new budesonide-MMX(R) 9 mg extended-release
tablets in patients with active left-sided ulcerative colitis. J Crohns
Colitis 2010;4:15360.
106. Miele E, Pascarella F, Giannetti E, et al. Effect of a probiotic
preparation (VSL#3) on induction and maintenance of remission in
children with ulcerative colitis. Am J Gastroenterol 2009;104:43743.
107. Burke DA, Axon AT, Clayden SA, et al. The efficacy of tobramycin
in the treatment of ulcerative colitis. Aliment Pharmacol Ther 1990;
4:1239.
108. Lobo AJ, Burke DA, Sobala GM, et al. Oral tobramycin in ulcerative
colitis: effect on maintenance of remission. Aliment Pharmacol Ther
1993;7:1558.
109. Gionchetti P, Rizzello F, Ferrieri A, et al. Rifaximin in patients with
moderate or severe ulcerative colitis refractory to steroid-treatment: a
double-blind, placebo-controlled trial. Dig Dis Sci 1999;44:12201.
110. Ohkusa T, Kato K, Terao S, et al. Newly developed antibiotic combination therapy for ulcerative colitis: a double-blind placebo-controlled
multicenter trial. Am J Gastroenterol 2010;105:18209.
111. Mantzaris GJ, Archavlis E, Christoforidis P, et al. A prospective
randomized controlled trial of oral ciprofloxacin in acute ulcerative
colitis. Am J Gastroenterol 1997;92:4546.
112. Turunen UM, Farkkila MA, Hakala K, et al. Long-term treatment of
ulcerative colitis with ciprofloxacin: a prospective, double-blind,
placebo-controlled study. Gastroenterology 1998;115:10728.
113. Muniyappa P, Gulati R, Mohr F, et al. Use and safety of rifaximin in
children with inflammatory bowel disease. J Pediatr Gastroenterol
Nutr 2009;49:4004.
114. Khan KJ, Ullman TA, Ford AC, et al. Antibiotic therapy in
inflammatory bowel disease: a systematic review and meta-analysis.
Am J Gastroenterol 2011;106:66173.
115. Henker J, Muller S, Laass MW, et al. Probiotic Escherichia coli Nissle
1917 (EcN) for successful remission maintenance of ulcerative colitis
in children and adolescents: an open-label pilot study. Z Gastroenterol
2008;46:8745.
116. Naidoo K, Gordon M, Fagbemi AO, et al. Probiotics for maintenance
of remission in ulcerative colitis. Cochrane Database Syst Rev 2011;
CD007443
117. Huynh HQ, deBruyn J, Guan L, et al. Probiotic preparation VSL#3
induces remission in children with mild to moderate acute ulcerative
colitis: a pilot study. Inflamm Bowel Dis 2009;15:7608.
118. Bibiloni R, Fedorak RN, Tannock GW, et al. VSL#3 probiotic-mixture
induces remission in patients with active ulcerative colitis. Am J
Gastroenterol 2005;100:153946.
119. Tursi A, Brandimarte G, Papa A, et al. Treatment of relapsing mild-tomoderate ulcerative colitis with the probiotic VSL#3 as adjunctive to
a standard pharmaceutical treatment: a double-blind, randomized,
placebo-controlled study. Am J Gastroenterol 2010;105:221827.
120. Sood A, Midha V, Makharia GK, et al. The probiotic preparation,
VSL#3 induces remission in patients with mild-to-moderately active
ulcerative colitis. Clin Gastroenterol Hepatol 2009;7:12029.
121. Guslandi M, Giollo P, Testoni PA. A pilot trial of Saccharomyces
boulardii in ulcerative colitis. Eur J Gastroenterol Hepatol 2003;15:
6978.
122. Furrie E, Macfarlane S, Kennedy A, et al. Synbiotic therapy
(Bifidobacterium longum/Synergy 1) initiates resolution of inflammation in patients with active ulcerative colitis: a randomised controlled
pilot trial. Gut 2005;54:2429.
123. Kato K, Mizuno S, Umesaki Y, et al. Randomized placebo-controlled
trial assessing the effect of bifidobacteria-fermented milk on active
ulcerative colitis. Aliment Pharmacol Ther 2004;20:113341.
124. Zocco MA, dal Verme LZ, Cremonini F, et al. Efficacy of Lactobacillus
GG in maintaining remission of ulcerative colitis. Aliment Pharmacol
Ther 2006;23:156774.
www.jpgn.org
357
Copyright 2012 by ESPGHAN and NASPGHAN. Unauthorized reproduction of this article is prohibited.
Turner et al
146. Russell RK, Wilson ML, Loganathan S, et al. A British Society of
Paediatric Gastroenterology, Hepatology and Nutrition survey of the
effectiveness and safety of adalimumab in children with inflammatory
bowel disease. Aliment Pharmacol Ther 2011;33:94653.
147. Veereman-Wauters G, de Ridder L, Veres G, et al. Risk of
infection and prevention in pediatric patients with IBD: ESPGHAN
IBD Porto Group commentary. J Pediatr Gastroenterol Nutr 2012
Feb 10. [Epub ahead of print]
148. Kandiel A, Fraser AG, Korelitz BI, et al. Increased risk of lymphoma
among inflammatory bowel disease patients treated with azathioprine
and 6-mercaptopurine. Gut 2005;54:11215.
149. Beaugerie L, Brousse N, Bouvier AM, et al. Lymphoproliferative
disorders in patients receiving thiopurines for inflammatory bowel
disease: a prospective observational cohort study. Lancet 2009;
374:161725.
150. Kotlyar DS, Osterman MT, Diamond RH, et al. A systematic review of
factors that contribute to hepatosplenic T-cell lymphoma in patients
with inflammatory bowel disease. Clin Gastroenterol Hepatol 2011;
9:3641.
151. Osterman MT, Kundu R, Lichtenstein GR, et al. Association of
6-thioguanine nucleotide levels and inflammatory bowel disease
activity: a meta-analysis. Gastroenterology 2006;130:104753.
152. Gazouli M, Pachoula I, Panayotou I, et al. Thiopurine S-methyltransferase genotype and the use of thiopurines in paediatric inflammatory
bowel disease Greek patients. J Clin Pharm Ther 2010;35:937.
153. Ooi CY, Bohane TD, Lee D, et al. Thiopurine metabolite monitoring in
paediatric inflammatory bowel disease. Aliment Pharmacol Ther 2007;
25:9417.
154. Gerich ME, Quiros JA, Marcin JP, et al. A prospective evaluation of
the impact of allopurinol in pediatric and adult IBD patients with
preferential metabolism of 6-mercaptopurine to 6-methylmercaptopurine. J Crohns Colitis 2010;4:54652.
155. Rahhal RM, Bishop WP. Initial clinical experience with allopurinolthiopurine combination therapy in pediatric inflammatory bowel
disease. Inflamm Bowel Dis 2008;14:167882.
156. Oren R, Arber N, Odes S, et al. Methotrexate in chronic active
ulcerative colitis: a double-blind, randomized, Israeli multicenter trial.
Gastroenterology 1996;110:141621.
157. Onuk MD, Kaymakoglu S, Demir K, et al. Low-dose weekly
methotrexate therapy in remission maintenance in ulcerative colitis.
Gut 1996;39:A75.
158. Aloi M, Di Nardo G, Conte F, et al. Methotrexate in paediatric
ulcerative colitis: a retrospective survey at a single tertiary referral
centre. Aliment Pharmacol Ther 2010;32:101722.
159. Turner D, Griffiths AM. Acute severe ulcerative colitis in children:
a systematic review. Inflamm Bowel Dis 2011;17:4409.
160. Ziring DA, Wu SS, Mow WS, et al. Oral tacrolimus for steroiddependent and steroid-resistant ulcerative colitis in children. J Pediatr
Gastroenterol Nutr 2007;45:30611.
161. Yamamoto S, Nakase H, Matsuura M, et al. Tacrolimus therapy as an
alternative to thiopurines for maintaining remission in patients with
refractory ulcerative colitis. J Clin Gastroenterol 2011;45:52630.
162. Lawson MM, Thomas AG, Akobeng AK. Tumour necrosis factor
alpha blocking agents for induction of remission in ulcerative colitis.
Cochrane Database Syst Rev. 2006;CD005112
163. Rutgeerts P, Sandborn WJ, Feagan BG, et al. Infliximab for induction
and maintenance therapy for ulcerative colitis. N Engl J Med 2005;
353:246276.
164. Hyams J, Damaraju L, Blank M, et al. Induction and maintenance
therapy with infliximab for children with moderate to severe ulcerative
colitis. Clin Gastroenterol Hepatol 2012;10:3919.
165. Hyams JS, Lerer T, Griffiths A, et al. Outcome following infliximab
therapy in children with ulcerative colitis. Am J Gastroenterol 2010;
105:14306.
166. Reinisch W, Sandborn WJ, Hommes DW, et al. Adalimumab
for induction of clinical remission in moderately to severely active
ulcerative colitis: results of a randomised controlled trial. Gut 2011;
60:7807.
167. Sandborn WJ, van Assche G, Reinisch W, et al. Adalimumab induces
and maintains clinical remission in patients with moderate-to-severe
ulcerative colitis. Gastroenterology 2012;142:25765.
358
JPGN
www.jpgn.org
Copyright 2012 by ESPGHAN and NASPGHAN. Unauthorized reproduction of this article is prohibited.
JPGN
190. Turner D, Steinhart AH, Griffiths AM. Omega 3 fatty acids (fish oil)
for maintenance of remission in ulcerative colitis. Cochrane Database
Syst Rev. 2007:CD006443
191. Bernstein CN, Fried M, Krabshuis JH, et al. World Gastroenterology
Organization Practice Guidelines for the diagnosis and management of
IBD in 2010. Inflamm Bowel Dis 2010;16:11224.
192. Tilney HS, Constantinides V, Ioannides AS, et al. Pouch-anal
anastomosis vs straight ileoanal anastomosis in pediatric patients: a
meta-analysis. J Pediatr Surg 2006;41:1799808.
193. Seetharamaiah R, West BT, Ignash SJ, et al. Outcomes in pediatric
patients undergoing straight vs J pouch ileoanal anastomosis: a multicenter analysis. J Pediatr Surg 2009;44:14107.
194. Pakarinen MP, Natunen J, Ashorn M, et al. Long-term outcomes
of restorative proctocolectomy in children with ulcerative colitis.
Pediatrics 2009;123:137782.
195. Weston-Petrides GK, Lovegrove RE, Tilney HS, et al. Comparison of
outcomes after restorative proctocolectomy with or without
defunctioning ileostomy. Arch Surg 2008;143:40612.
196. Tjandra JJ, Fazio VW, Milsom JW, et al. Omission of temporary
diversion in restorative proctocolectomyis it safe? Dis Colon
Rectum 1993;36:100714.
197. Ahmed Ali U, Keus F, Heikens JT, et al. Open versus laparoscopic
(assisted) ileo pouch anal anastomosis for ulcerative colitis and
familial adenomatous polyposis. Cochrane Database Syst Rev.
2009;CD006267
198. Wu XJ, He XS, Zhou XY, et al. The role of laparoscopic surgery
for ulcerative colitis: systematic review with meta-analysis. Int J
Colorectal Dis 2010;25:94957.
199. Fraser JD, Garey CL, Laituri CA, et al. Outcomes of laparoscopic and
open total colectomy in the pediatric population. J Laparoendosc Adv
Surg Tech A 2010;20:65960.
200. Mattioli G, Pini-Prato A, Barabino A, et al. Laparoscopic approach for
children with inflammatory bowel diseases. Pediatr Surg Int 2011;
27:83946.
201. da Luz Moreira A, Kiran RP, Lavery I. Clinical outcomes of ileorectal
anastomosis for ulcerative colitis. Br J Surg 2010;97:659.
202. Cornish JA, Tan E, Teare J, et al. The effect of restorative proctocolectomy on sexual function, urinary function, fertility, pregnancy and
delivery: a systematic review. Dis Colon Rectum 2007;50:112838.
203. Waljee A, Waljee J, Morris AM, et al. Threefold increased risk of
infertility: a meta-analysis of infertility after ileal pouch anal anastomosis in ulcerative colitis. Gut 2006;55:157580.
204. Mortier PE, Gambiez L, Karoui M, et al. Colectomy with ileorectal
anastomosis preserves female fertility in ulcerative colitis. Gastroenterol Clin Biol 2006;30:5947.
205. Markel TA, Lou DC, Pfefferkorn M, et al. Steroids and poor nutrition
are associated with infectious wound complications in children
undergoing first stage procedures for ulcerative colitis. Surgery
2008; 144:5405.
206. Randall J, Singh B, Warren BF, et al. Delayed surgery for acute severe
colitis is associated with increased risk of postoperative complications.
Br J Surg. 2010;97:4049.
207. Yang Z, Wu Q, Wu K, et al. Meta-analysis: pre-operative infliximab
treatment and short-term post-operative complications in patients with
ulcerative colitis. Aliment Pharmacol Ther 2010;31:48692.
208. Kappelman M, Horvath-Puho E, Sandler RS, et al. The association
between IBD and venous thromboembolism in Danish children and
adults: A population-based case-control study. Gastroenterology
2010;138:S-105 6
209. Rintala RJ, Lindahl HG. Proctocolectomy and J-pouch ileo-anal
anastomosis in children. J Pediatr Surg 2002;37:6670.
210. Alexander F, Sarigol S, DiFiore J, et al. Fate of the pouch in 151
pediatric patients after ileal pouch anal anastomosis. J Pediatr Surg
2003;38:7882.
211. Stavlo PL, Libsch KD, Rodeberg DA, et al. Pediatric ileal pouch-anal
anastomosis: functional outcomes and quality of life. J Pediatr Surg
2003;38:9359.
212. Robb BW, Gang GI, Hershko DD, et al. Restorative proctocolectomy
with ileal pouch-anal anastomosis in very young patients with
refractory ulcerative colitis. J Pediatr Surg 2003;38:8637.
213. Perrault J. Pouchitis in children: therapeutic options. Curr Treat
Options Gastroenterol 2002;5:38997.
www.jpgn.org
214. Shen B, Lashner BA, Bennett AE, et al. Treatment of rectal cuff
inflammation (cuffitis) in patients with ulcerative colitis following
restorative proctocolectomy and ileal pouch-anal anastomosis. Am J
Gastroenterol 2004;99:152731.
215. Slatter C, Girgis S, Huynh H, et al. Pre-pouch ileitis after colectomy in
paediatric ulcerative colitis. Acta Paediatr 2008;97:3813.
216. Shen B, Achkar JP, Lashner BA, et al. Irritable pouch syndrome: a new
category of diagnosis for symptomatic patients with ileal pouch-anal
anastomosis. Am J Gastroenterol 2002;97:9727.
217. Biancone L, Michetti P, Travis SP, et al. European evidence based
consensus on the management of ulcerative colitis: special situations.
J Crohns Colitis 2008;2:6392.
218. Kaditis AG, Perrault J, Sandborn WJ, et al. Antineutrophil cytoplasmic
antibody subtypes in children and adolescents after ileal pouch-anal
anastomosis for ulcerative colitis. J Pediatr Gastroenterol Nutr
1998;26:38692.
219. Holubar SD, Cima RR, Sandborn WJ, et al. Treatment and prevention
of pouchitis after ileal-pouch anal anastomosis for ulcerative colitis.
Cochrane Database Syst Rev. 2010;CD001176.
220. Ferrante M, D Haens G, Dewit O, et al. Efficacy of infliximab in
refractory pouchitis and Crohns disease-related complications of the
pouch: a Belgian case series. Inflamm Bowel Dis 2010;16:2439.
221. Mimura T, Rizzello F, Helwig U, et al. Once daily high dose probiotic
therapy (VSL#3) for maintaining remission in recurrent or refractory
pouchitis. Gut 2004;53:10814.
222. Gionchetti P, Rizzello F, Venturi A, et al. Oral bacteriotherapy as
maintenance treatment in patients with chronic pouchitis: a doubleblind, placebo-controlled trial. Gastroenterology 2000;119:3059.
223. Aloi M, Cucchiara S. Extradigestive manifestations of IBD in
pediatrics. Eur Rev Med Pharmacol Sci 2009;13(suppl 1):2332.
224. Jose FA, Garnett EA, Vittinghoff E, et al. Development of
extraintestinal manifestations in pediatric patients with inflammatory
bowel disease. Inflamm Bowel Dis 2009;15:638.
225. Dotson JL, Hyams JS, Markowitz J, et al. Extraintestinal manifestations of pediatric inflammatory bowel disease and their relation
to disease type and severity. J Pediatr Gastroenterol Nutr 2010;
51:1405.
226. Hyams JS. Extraintestinal manifestations of inflammatory bowel
disease in children. J Pediatr Gastroenterol Nutr 1994;19:721.
227. Hyams JS. Crohns disease in children. Pediatr Clin North Am
1996;43:25577.
228. Winesett M. Inflammatory bowel disease in children and adolescents.
Pediatr Ann 1997;26:22734.
229. Mamula P, Markowitz JE, Baldassano RN. Inflammatory bowel
disease in early childhood and adolescence: special considerations.
Gastroenterol Clin North Am 2003;32:96795.
230. Bonner GF, Fakhri A, Vennamaneni SR. A long-term cohort study
of nonsteroidal anti-inflammatory drug use and disease activity in
outpatients with inflammatory bowel disease. Inflamm Bowel Dis
2004;10:7517.
231. Orchard TR, Jewell DP. Conditions of the eyes and joints
associated with inflammatory bowel disease. In: Targan SR, Shanahan
F, Karp LC, eds. Inflammatory Bowel Disease: Translating Basic
Science Into Clinical Practice. Chichester, UK: John Wiley & Sons
Ltd; 2010:55361.
232. Charatcharoenwitthaya P, Lindor KD. Primary sclerosing cholangitis:
diagnosis and management. Curr Gastroenterol Rep 2006;8:7582.
233. Broome U, Lofberg R, Veress B, et al. Primary sclerosing cholangitis
and ulcerative colitis: evidence for increased neoplastic potential.
Hepatology 1995;22:14048.
234. Fevery J, Henckaerts L, Van Oirbeek R, et al. Malignancies and
mortality in 200 patients with primary sclerosering cholangitis:
a long-term single-centre study. Liver Int 2012;32:21422.
235. Cullen SN, Chapman RW. The medical management of primary
sclerosing cholangitis. Semin Liver Dis 2006;26:5261.
236. Pardi DS, Loftus EV Jr, Kremers WK, et al. Ursodeoxycholic acid as a
chemopreventive agent in patients with ulcerative colitis and primary
sclerosing cholangitis. Gastroenterology 2003;124:88993.
237. Lindor KD, Kowdley KV, Luketic VA, et al. High-dose ursodeoxycholic acid for the treatment of primary sclerosing cholangitis.
Hepatology 2009;50:80814.
359
Copyright 2012 by ESPGHAN and NASPGHAN. Unauthorized reproduction of this article is prohibited.
Turner et al
238. Eaton JE, Silveira MG, Pardi DS, et al. High-dose ursodeoxycholic
acid is associated with the development of colorectal neoplasia in
patients with ulcerative colitis and primary sclerosing cholangitis.
Am J Gastroenterol 2011;106:163845.
239. Rocha R, Santana GO, Almeida N, et al. Analysis of fat and muscle
mass in patients with inflammatory bowel disease during remission and
active phase. Br J Nutr 2009;101:6769.
240. Sawczenko A, Sandhu BK. Presenting features of inflammatory bowel
disease in Great Britain and Ireland. Arch Dis Child 2003;88:995
1000.
241. Markowitz J, Grancher K, Rosa J, et al. Growth failure in pediatric
inflammatory bowel disease. J Pediatr Gastroenterol Nutr 1993;
16:37380.
242. Turunen P, Ashorn M, Auvinen A, et al. Long-term health outcomes
in pediatric inflammatory bowel disease: a population-based study.
Inflamm Bowel Dis 2009;15:5662.
243. Gonzalez-Huix F, Fernandez-Banares F, Esteve-Comas M, et al.
Enteral versus parenteral nutrition as adjunct therapy in acute ulcerative colitis. Am J Gastroenterol 1993;88:22732.
244. McIntyre PB, Powell-Tuck J, Wood SR, et al. Controlled trial of bowel
rest in the treatment of severe acute colitis. Gut 1986;27:4815.
245. Dickinson RJ, Ashton MG, Axon AT, et al. Controlled trial of
intravenous hyperalimentation and total bowel rest as an adjunct to
the routine therapy of acute colitis. Gastroenterology 1980;79:1199
204.
246. Barabino A, Tegaldo L, Castellano E, et al. Severe attack of ulcerative
colitis in children: retrospective clinical survey. Dig Liver Dis 2002;
34:449.
247. Bechtold S, Alberer M, Arenz T, et al. Reduced muscle mass and bone
size in pediatric patients with inflammatory bowel disease. Inflamm
Bowel Dis 2010;16:21625.
248. Werkstetter KJ, Pozza SB, Filipiak-Pittroff B, et al. Long-term
development of bone geometry and muscle in pediatric inflammatory
bowel disease. Am J Gastroenterol 2011;106:98898.
249. Gokhale R, Favus MJ, Karrison T, et al. Bone mineral density
assessment in children with inflammatory bowel disease. Gastroenterology 1998;114:90211.
250. Sylvester FA, Wyzga N, Hyams JS, et al. Natural history of bone
metabolism and bone mineral density in children with inflammatory
bowel disease. Inflamm Bowel Dis 2007;13:4250.
251. Walther F, Fusch C, Radke M, et al. Osteoporosis in pediatric patients
suffering from chronic inflammatory bowel disease with and without
steroid treatment. J Pediatr Gastroenterol Nutr 2006;43:4251.
252. Pappa H, Thayu M, Sylvester F, et al. Skeletal health of children and
adolescents with inflammatory bowel disease. J Pediatr Gastroenterol
Nutr 2011;53:1125.
360
JPGN
253. Pappa HM, Gordon CM, Saslowsky TM, et al. Vitamin D status
in children and young adults with inflammatory bowel disease.
Pediatrics 2006;118:195061.
254. Greenley RN, Stephens M, Doughty A, et al. Barriers to adherence
among adolescents with inflammatory bowel disease. Inflamm Bowel
Dis 2010;16:3641.
255. Greenley RN, Hommel KA, Nebel J, et al. A meta-analytic review
of the psychosocial adjustment of youth with inflammatory bowel
disease. J Pediatr Psychol 2011;35:85769.
256. Timmer A, Preiss JC, Motschall E, et al. Psychological interventions
for treatment of inflammatory bowel disease. Cochrane Database Syst
Rev. 2011:CD006913-CD006913.
257. Ross SC, Strachan J, Russell RK, et al. Psychosocial functioning and
health-related quality of life in paediatric inflammatory bowel disease.
J Pediatr Gastroenterol Nutr 2011;53:4808.
258. Mackner LM, Crandall WV. Long-term psychosocial outcomes
reported by children and adolescents with inflammatory bowel disease.
Am J Gastroenterol 2005;100:138692.
259. Vaisto T, Aronen ET, Simola P, et al. Psychosocial symptoms and
competence among adolescents with inflammatory bowel disease and
their peers. Inflamm Bowel Dis 2010;16:2735.
260. Hommel KA, Denson LA, Baldassano RN. Oral medication adherence
and disease severity in pediatric inflammatory bowel disease. Eur J
Gastroenterol Hepatol 2011;23:2504.
261. Hommel KA, Baldassano RN. Barriers to treatment adherence in
pediatric inflammatory bowel disease. J Pediatr Psychol 2010;
35:100510.
262. Reed-Knight B, Lewis JD, Blount RL. Association of disease, adolescent, and family factors with medication adherence in pediatric
inflammatory bowel disease. J Pediatr Psychol 2011;36:30817.
263. Goodhand J, Hedin CR, Croft NM, et al. Adolescents with IBD: the
importance of structured transition care. J Crohns Colitis 2011;5:
50919.
264. Crowley R, Wolfe I, Lock K, et al. Improving the transition between
paediatric and adult healthcare: a systematic review. Arch Dis Child
2011;96:54853.
265. Cassinotti A, Actis GC, Duca P, et al. Maintenance treatment with
azathioprine in ulcerative colitis: outcome and predictive factors after
drug withdrawal. Am J Gastroenterol 2009;104:27607.
266. Actis GC, Fadda M, Pellicano R, et al. The 17-year single-center
experience with the use of azathioprine to maintain remission in
ulcerative colitis. Biomed Pharmacother 2009;63:3625.
267. Turner D, Otley AR, Mack D, et al. Development and evaluation of a
Pediatric Ulcerative Colitis Activity Index (PUCAI): a prospective
multicenter study. Gastroenterology 2007;133:42332.
www.jpgn.org
Copyright 2012 by ESPGHAN and NASPGHAN. Unauthorized reproduction of this article is prohibited.
JPGN
Evaluation
1. The diagnosis of UC in children
2. The required investigations at baseline and differential diagnosis
3. Monitoring disease activity and remission in children
4. Predictors of severe disease course
Medical management
5. The role of antibiotics in pediatric UC (excluding pouchitis)
6. 5-ASA in pediatric UC
7. Thiopurines in pediatric UC
8. Methotrexate in pediatric UC
9. Corticosteroids in pediatric UC
10. Defining and managing steroid dependence
11. Defining and managing steroid refractoriness
12. Enemas in pediatric UC
13. Biologics in pediatric UC
14. Maintenance of remission: timing of choice of each medication
15. Probiotics in pediatric UC
16. Other investigational interventions
Surgical considerations
17. The preferred elective surgery in pediatric UC and indications
18. Ways to minimize surgical complications
19. Pouchitis in children
General considerations
20. Nutrition, growth, and bone health
21. Psychosocial support to the child and the family and transitional care
22. EIMs
23. Risks and adverse events
Item
Points
1. Abdominal pain
No pain
Pain can be ignored
Pain cannot be ignored
2. Rectal bleeding
None
Small amount only, in <50% of stools
Small amount with most stools
Large amount (>50% of the stool content)
3. Stool consistency of most stools
Formed
Partially formed
Completely unformed
4. Number of stools per 24 hours
02
35
68
>8
5. Nocturnal stools (any episode causing awakening)
No
Yes
6. Activity level
No limitation of activity
Occasional limitation of activity
Severe restricted activity
Sum of PUCAI (085)
0
5
10
0
10
20
30
0
5
10
0
5
10
15
0
10
0
5
10
For users guide and cutoff values for response, remission, mild,
moderate, and severe disease activity, refer to the original study (267).
Appendix 2: Levels of evidence and grades of recommendation based on the Oxford Centre for Evidence-based Medicine
Level
1a
1b
1c
Diagnostic study
SR with homogeneity of level 1 diagnostic studies
Validating cohort study with good reference standard
Specificity or sensitivity is so high that a positive or
a negative result rules out the diagnosis
SR with homogeneity of level >2 diagnostic studies
Exploratory cohort study with good reference standards
2a
2b
2c
3a
3b
4
5
Therapeutic study
SR with homogeneity of RCTs
Individual RCT (with narrow CI)
All or none
SR (with homogeneity) of cohort studies
Individual cohort study (including low-quality
RCT; eg, <80% follow-up)
Outcomes research; ecological studies
SR with homogeneity of case-control studies
Individual case-control study
Case series (and poor-quality cohort and casecontrol studies)
Expert opinion without explicit critical appraisal,
or based on physiology, bench research or
first principles
Grading of recommendation
A Consistent level 1 studies
B Consistent level 2 or 3 studies or extrapolations from level 1 studies
C Level 4 studies or extrapolations from level 2 or 3 studies
D Level 5 evidence or troublingly inconsistent or inconclusive studies of any level
For details, see http://www.cebm.net/levels_of_evidence.asp#refs.
www.jpgn.org
361
Copyright 2012 by ESPGHAN and NASPGHAN. Unauthorized reproduction of this article is prohibited.